A 25–year–old previously healthy man, presented with a 3–month history of intermittent pleuritic chest pain, dyspnea and intermittent hemoptysis after returning from a trip to Europe. He was treated with oral antibiotics for presumed pneumonia with no improvement of symptoms; a chest roentgenogram and a computed tomography (CT) revealed a large subcarinal cyst and was subsequently referred to our institution. Review of the CT raised suspicion for pulmonary infarction and imaging was repeated, showing subacute right upper and right middle lobe thrombus; in addition a 6.5 × 5.5 cm cystic lesion in the subcarinal region compatible with a large bronchogenic cyst with mass effect on the right superior pulmonary vein was documented. Hypercoagulable panel revealed that he was heterozygous for Factor V Leiden. Patient was discharged after initiating anticoagulation with enoxaparin and bridging to coumadin. He was readmitted 1 week later due to persistence of symptoms despite appropriate anticoagulation. Repeat imaging of the chest revealed a peripheral patchy consolidative opacity within the right upper and right middle lobes consistent with pulmonary venous infarcts. It was considered that this was secondary to local effect of the bronchogenic cyst and the patient underwent a right thoracotomy with excision of cyst and a wedge excision of the right upper lobe. Spirometry previous to surgery revealed normal lung volumes. The histopathology report showed “organizing pneumonia with areas of infarction” and a “fibrous walled cyst with respiratory epithelium, hyaline cartilage and submucosal glands, consistent with bronchogenic cyst”. The patient was discharged one week after surgery and remained on systemic anticoagulation with enoxaparin which was stopped 6 weeks after surgery. He remained asymptomatic afterwards and was educated to have prophylactic anticoagulation in cases of prolonged immobilization or acute medical issues requiring hospitalization.
Bronchogenic cysts are the most common cystic masses in the mediastinum. They arise from abnormal foregut malformations. They are most commonly an incidental finding on chest imaging. Although generally asymptomatic, they can rupture into adjacent structures or cause airway and vascular compression such as in our patient. Histopathology shows a thick wall that contains smooth muscle, glands, and cartilage. The treatment is surgical excision. Our patient had a potentially life– threatening complications secondary to vascular compression. The surgical treatment was considered curative. Our patient was heterozygous for Factor V Leiden which can certainly cause an increased predisposition for thrombosis in a predisposing clinical scenario.
Bronchogenic cyst with local mass effect should be removed to avoid the potential for life–threatening complications. Anticoagulation for a situational blood clot can be safely stopped 6 weeks after surgery.